Ngo Elizabeth, Patel Nachiket, Chandrasekaran Krishnaswamy, Tajik A Jamil, Paterick Timothy E
J Med Pract Manage. 2016 Mar-Apr;31(5):305-8.
Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology.
在病历中进行全面、详细的记录对于患者护理以及在出现过失指控时对医生来说至关重要。因此，医生最好清楚地了解这种记录。了解谁负责记录、记录什么重要内容、何时记录以及如何记录很重要。此外，还应了解病历归谁所有、向电子病历过渡的意义、使用电子病历时的问题和陷阱，以及《经济和临床健康医疗信息技术法案》如何影响医疗服务提供者和医疗信息技术。
